Study Of Maternal Near Miss Events At The Tertiary Care Hospital

Background:A maternal near miss case is defined as a “a woman who nearly died but survived a complication that occurred during pregnancy,child birth or within 42 days of termination of pregnancy”1.MMR is defined as ratio of number of maternal deaths per 1000 live births. All pregnant women deserve a good quality of care especially Emergency Obstetric Care including proper infrastructure, human resources that can detect and manage such complications earliest. The objective of this study was to evaluate the causes of maternal near miss cases, various management modalities performed and maternal and fetal outcome in near miss cases. Material And Methods:A retrospective study was carried out in obstetrics and gynaecology department of SCL municipal general hospital, Ahmedabad for identification of MNM as per MNM-R operational guidelines (2014) in a tertiary care hospital from August 2020 to March 2022. Result:Total deliveries during our study period were 9266 out of which 535 number of patients developed complications, 75 patients ended up becoming near miss cases and 30 maternal mortalities were observed.Hypertensive disorders (38.6%) followed by severe anemia (18.6%) and haemorrhage (13.3%) were the commonest underlying causes leading to MNM. More than one management modality was followed in one case. 25% of patients required blood transfusion. Out of which 11 patients required massive blood transfusion (>5 units of blood) and 16% of patients required blood products along with blood resulting from either severe anemia or altered coagulopathy (DIC). 69.3% of patients required ICU stay of <5 days and majority of patients required hospital stay of 9-14 days.63.6% of patients required ICU stay of 1-4 days.Live birth rate was 82.6%.Conclusion:Maternal health is the direct indicator of prevailing health status in a country. Reduction in maternal mortality is one of the targets of MILLENIUM DEVELOPMENT GOALS13for 2015 but in spite of full efforts by all the health care professionals, it still remains a challenge in developing countries.There should be prompt and proper management of high-risk groups by frequent antenatal visits. Aggressive management of each complication and close monitoring of women in labour, decision making in mode and time of termination of pregnancy are important to prevent further complications.

Risk Factors for Patients Using Intraoperative Vasopressor Infusions During Carotid Body Tumor Excision / 中国医学科学院学报

Objective To investigate the risk factors for patients using intraoperative vasopressor infusions during carotid body tumor(CBT)excision.Patients' mean arterial pressure(MAP)and heart rate(HR)fluctuations as well as their requirements for vasoactive agents during surgery were assessed. Methods The patients receiving CBT excision in Peking Union Medical College Hospital from May 1,2013 to July 31,2017 were included for a retrospective cohort study.The potential factors of intraoperative requirement for vasopressor infusions were investigated using univariate analysis and Logistic multivariate analysis.Furthermore,the relationships of Shamblin types of CBT with intraoperative MAP/HR fluctuations and requirements for vasoactive agents were analyzed. Results A total of 108 patients with 116 CBTs were included.Univariate analysis revealed that maximum tumor diameter >4 cm,intraoperative internal carotid artery injury,internal carotid artery reconstruction,malignant pathology,advanced Shamblin types(type Ⅱ and Ⅲ),estimated blood loss ≥400 ml,and operation duration >4 hours were associated with intraoperative requirements for vasopressor infusions.Logistic analysis showed that Shamblin type Ⅲ(OR=2.286,95% CI=1.324-14.926,P=0.016)and operation duration >4 hours(OR=3.874,95% CI=1.020-14.623,P=0.046)were risk factors for intraoperative requirements for vasopressor infusions during CBT surgery.In addition,Shamblin type Ⅲ was associated with intraoperative abnormal HR elevation and requirements for vasopressors.Conclusions Shamblin type Ⅲ and operation duration>4 hours are risk factors for intraoperative requirements of patients for using vasopressor infusions during CBT surgery.Shamblin type Ⅲ is associated with intraoperative abnormal HR elevation and requirements for vasopressors.

Comparison of Hemodynamic Response and Vasopressor Requirement Following Spinal Anesthesia between Normotensive and Hypertensive Women Undergoing Elective Cesarean Section

Introduction: Spinal anesthesia (SA) is the technique of choice in cesarean sections, but it is not widely accepted in hypertensiondue to fear of sudden and extensive sympathetic blockade. Sympathetic blockade induced hypotension may occur in up to64–100% of pregnant women who have been given spinal anesthesia for cesarean delivery, especially when hyperbaric solutionsare used. Severely pre-eclamptic patients were previously believed to be at high risk of severe hypotension, with maternaland fetal consequences because of reduced plasma volume and because of the need to limit i.v. fluids to avoid iatrogenicpulmonary edema.Methodology: The present study, “comparison of hemodyanamic response and vasopressor requirement following spinalanesthesia between normotensive and hypertensive women undergoing elective cesarean section” 100 women of age20–35 years, the American Society of Anesthesiologists physical Status Ι and ΙΙ carrying a singleton pregnancy and scheduledto have elective cesarean section in Netaji Subhash Chandra Bose Medical College, Jabalpur, were enrolled into two groups.GroupA: 50 were normotensive women and Group B: 50 were hypertensive women. All patients received a standard subarachnoidblock under all aseptic precautions with 12.5 mg 0.5% hyperbaric bupivacaine.Results: Based on the data from our study, it could be concluded that after spinal anesthesia in patients undergoing electivecesarean section-hypertensive group of parturients had less fall in mean systolic blood pressure (SBP), diastolic BP, and meanarterial BP in comparison to normal healthy pregnant women which were statistically significant (P < 0.05). Hypertensive group ofpatients required less ephedrine to treat hypotension in comparison to normotensive patients which were statistically significant(P < 0.05). The incidence of hypotension was almost 7 times less in hypertensive parturients than healthy parturients (oddsratio = 23.14, relative risk of hypotension in Group A = 7.2, confidence interval = 7.6–70.3).Conclusion: To summarize, our results showed that hypotension following SA administered for cesarean section wassignificantly less in hypertensive patient than in healthy pregnant women. In addition, vasopressor requirements were also lessin hypertensive parturients and neonatal outcome was comparable between the two groups. Therefore, subarachnoid blockis an acceptable technique to perform in hypertensive parturients due to its virtue of simplicity, rapidity, cost-effectiveness,and intensity of block.

Vasopressor Discontinuation Order in the Recovery Phase of Septic Shock: A Systematic Review and Meta-Analysis

@#BACKGROUND: Septic shock causes life threatening organ dysfunction needing vasopressor despite adequate fluid resuscitation. Numerous studies and meta-analysis have proven norepinephrine as the initial vasopressor of choice in septic shock with vasopressin as add-on. Although guidelines have established the goal monitoring response in septic shock, optimal approach in discontinuation of the vasopressors in the recovery phase of septic shock remains limited. METHODS: A systematic review and meta-analysis was performed on randomized controlled trials (RCTs) and nonrandomized studies comparing incidence of hypotension within 24 hours of discontinuing norepinephrine first versus vasopressin. Three reviewers independently selected studies, assessed their quality, and extracted the following data: the number and characteristics of patients enrolled, inclusion and exclusion criteria for each study, the description of interventions (discontinuing norepinephrine first versus discontinuing vasopressin first) and outcomes (incidence of hypotension within 24 hours). RESULTS: Seven retrospective cohort studies and one prospective randomized control trial were included. Compared with norepinephrine, risk of hypotension is higher when vasopressin is discontinued first among patients in the recovery phase of septic shock (RR 2.06; 95% CI [1.11,3.82]; I 2 91%). Results were consistent in the subgroup analysis after excluding abstract-only and poor-quality studies (RR 1.73; 95% CI [0.74, 4.03]; I 2 93%). There is no difference in ICU (RR 0.97; 95% CI [0.71, 1.32]; I 2 38%) and in-hospital mortality (RR 0.88; 95% CI [0.66, 1.16]; I 2 41%) between the two vasopressor weaning strategies. Finally ICU length of stay was reported on 5 studies with no significant difference between the two strategies. CONCLUSION: Based on the results, there is increased risk of hypotension when vasopressin is discontinued first versus norepinephrine.

A prospective observational study involving three fixed infusion regimens of phenylephrine for hemodynamic support during spinal anaesthesia for caesarian delivery

Background: Spinal anaesthesia used in caesarian section is associated with hypotension which can have maternal and fetal side effects. To determine the efficacy and ideal dosing of Phenylephrine in attenuating the hypotensive episodes during caesarean section under spinal anaesthesia.Methods: 100 patients were allocated to four groups, placebo group (PE 0) and 3 fixed phenylephrine infusion regimens, phenylephrine 25 μg/min-1 (PE 25), phenylephrine 50 μg/min-1 (PE 50), and phenylephrine 75 μg/min-1 (PE 75). Blood pressure, heart rate were noted among primary variables and fetal parameters like umbilical blood pH and lactate were recorded as secondary parameters.Results: There was a significant reduction in heart rate with increasing the infusion dosage of phenylephrine, with a mean of 86.8 beats/min at the end of procedure in placebo group and 69.4 beats/min in 75 μg group (p value <0.001). There was significant statistical difference among systolic blood pressure in the four groups after 7 min of the procedure and p-value of <0.05 with better attenuation of hypotension in infusion groups as compared to placebo. Similarly there was significant statistical difference in diastolic blood pressure among the four groups after 8 min of the procedure with p values <0.05.Conclusions: Prophylactic phenylephrine infusions reduced the incidence and severity of maternal pre-delivery hypotension. Among the fixed rate phenylephrine infusion regimens investigated, infusion rates of 50 μg/min-1 were associated with greater maternal hemodynamic stability compared with 25 and 75 μg/min-1, with minimal side effects and intervention.

Passive pulmonary hypertension after cardiac surgery: from bench to bedside / 中国胸心血管外科临床杂志

@#In left heart disease, pulmonary artery pressure would increase due to the elevated left atrial pressure. This type of pulmonary hypertension (PH) is belonged to type Ⅱ as a passive PH (pPH) in its classification. The essential cause of pPH is excessive blood volume. Recently, we have identified another type of pPH, which is induced by vasopressors. Vasopressor-induced pPH shares similar pathophysiological manifestations with left heart disease-induced pPH. pPH would, therefore, be aggressive if vasopressors were applied in patients with left heart disease, which may be common after cardiac surgery, because heart undergoing surgical trauma may require support of vasopressors. Unfortunately, pPH after cardiac surgery is often ignored because of the difficulty in diagnosis. To improve the understanding of pPH and its effect on outcomes, here we highlight the mechanisms of interaction between vasopressor-induced and left heart failure-induced pPH, and provide insights into its therapeutic options.

Vasopresores en resucitación cardiopulmonar: la controversia continúa / Vasopressors for cardiopulmonary resuscitation

The Advanced Cardiac Life Support proposes the use of vasopressor drugs cardiopulmonary resuscitation, with the primary purpose of effectively and early restoration of spontaneous circulation. However, the increased return of spontaneous circulation with vasopressors has not improved neurological outcome at hospital discharge. Adrenaline has traditionally been the main tool of the cardiopulmonary resuscitation guidelines despite the lack of conclusive scientific evidence. Therefore other alternatives were considered at experimental level that has have failed to overcome the clinical results of this drug. In contrast to progress on the standardized management of cardiopulmonary resuscitation, the controversy regarding the effectiveness of vasopressor therapy remains open in the last years due to lack of clinical data to support their usefulness.

El soporte vital avanzado propone el uso de vasopresores durante la resucitación cardiopulmonar, con la finalidad primordial de reestablecer de manera precoz y efectiva la circulación espontánea. Sin embargo, el aumento del retorno a la circulación espontánea asociada a los vasopresores no ha demostrado una mejoría en el pronóstico neurológico al alta hospitalaria. La adrenalina, ha sido tradicionalmente la herramienta principal de las guías de resucitación cardiopulmonar pese a la falta de evidencia científica concluyente. Por ello se han planteado otras alternativas a nivel experimental que no han logrado superar los resultados de este fármaco a nivel clínico. En contraste con los avances respecto al manejo estandarizado de la resucitación cardiopulmonar, el debate con respecto a la efectividad de la terapia vasopresora se mantiene abierto en los últimos años dada la falta de datos clínicos que corroboren su real utilidad.

Norepinephrine infusion increases urine output in children under sedative and analgesic infusion / Infusão de noradrenalina aumenta o débito urinário de crianças recebendo drogas sedoanalgésicas

Objective: to evaluate the effects of early norepinephrine (NE) infusion in children submitted to mechanical ventilation (MV) requiring continuous sedative and analgesic infusion. Methods: double-blinded, randomized, placebo-controlled trial enrolling children (1 month to 12 years of age) admitted to a Brazilian PICU and expected to require MV and continuous sedative and analgesic drug infusions for at least five days. Children were randomized to receive either norepinephrine (NE) (0.15 mcg/kg/min) or normal saline infusion, started in the first 24 hours of MV, and maintained for 72 hours. We compared hemodynamic variables, fluid intake, renal function and urine output between groups. Results: forty children were equally allocated to the NE or placebo groups, with no differences in baseline characteristics, laboratorial findings, PRISM II score, length of MV, or mortality between groups. The average norepinephrine infusion was 0.143 mcg/kg/min. The NE group showed higher urine output (p = 0.016) and continuous increment in the mean arterial pressure compared to the baseline (p = 0.043). There were no differences in the remaining hemodynamic variables, fluid requirements, or furosemide administration. Conclusion: early norepinephrine infusion in children submitted to MV improves mean arterial pressure and increases urine output. These effects were attributed to reversion of vasoplegia induced by the sedative and analgesic drugs. .

Objetivo: avaliar os efeitos da infusão de noradrenalina (NA) em crianças submetidas a ventilação mecânica (VM) requerendo infusão contínua de sedoanalgesia. Métodos: estudo duplo cego, randomizado e placebo controlado envolvendo crianças de 1 mês a 12 anos, admitidas em uma UTI pediátrica brasileira com a expectativa de necessidade de VM e sedoanalgesia por, no mínimo, 5 dias. As crianças foram randomizadas a receber infusão de NA (0,15 mcg/kg/min) ou solução salina, iniciadas nas primeiras 24 horas de VM e mantidas por 72 horas. Comparamos as variáveis hemodinâmicas, oferta hídrica, função renal e débito urinário entre os dois grupos. Resultados: 40 crianças foram alocadas aos grupos NA e placebo, sem diferenças nas características basais, achados laboratoriais, escore PRISM II, tempo de VM ou mortalidade. A infusão média de NA foi 0,143 mcg/kg/min. O grupo NA apresentou maior débito urinário (p = 0,016) e aumento constante da pressão arterial média quando comparado aos níveis basais (p = 0,043). Não se observou diferenças nas demais variáveis hemodinâmicas, reposição hídrica ou no uso de furosemida. Conclusão: infusão precoce de NA em crianças submetidas a VM em uso sedoanalgesia promove aumento na pressão arterial média e aumento da diurese. Esses efeitos são atribuídos à reversão da vasoplegia induzida pelas drogas sedativas e analgésicas. .

Avaliação in vitro das propriedades antimicrobianas de vasopressores / In vitro evaluation of antimicrobial features of vasopressors / Evaluación in vitro de las propiedades antimicrobianas de vasopresores

Justificativa e objetivo: os medicamentos administrados como perfusão intravenosa podem ser contaminados durante as várias etapas de produção ou preparação. No entanto, estudos sobre os efeitos antibacterianos de vasopressores são muito raros. Este estudo investiga a atividade antimicrobiana in vitro das formas de vasopressores usados clinicamente. Materiais e métodos: atividades antimicrobianas in vitro de substâncias vasopressoras de diferentes concentrações foram investigadas com o uso da técnica de microdiluição. Os microrganismos empregados no teste foram: Escherichia coli ATCC 25922, Yersinia pseudotuberculosis ATCC 911, Pseudomonas aeruginosa ATCC 10145, Listeria monocytogenes ATCC 43251, Enterococcus faecalis ATCC 29212, Staphylococcus aureus ATCC 25923, Bacillus cereus 702 Roma, Mycobacterium smegmatis ATCC607, Candida albicans ATCC 60193 e Saccharomyces cerevisiae RSKK 251. Os ensaios antibacterianos foram feitos em caldo de cultura Mueller-Hinton (pH 7,3) e os ensaios antifúngicos em solução tampão de base nitrogenada para levedura (pH 7,0). Resultados: duas preparações diferentes de dopamina mostraram atividade antimicrobiana. Nenhuma outra substância do estudo mostrou qualquer atividade antimicrobiana. Conclusões: em nossa opinião, os efeitos antibacterianos da dopamina podem ser vantajosos para inibir a propagação de contaminação bacteriana durante a preparação das soluções para perfusão. Contudo, salientamos a importância do seguimento rigoroso das diretrizes de esterilização dos equipamentos e de assepsia durante todos os procedimentos feitos em unidades de terapia intensiva. .

Background: Drugs administered as intravenous infusion may be contaminated during several stages of production or preparation. However studies focusing on antibacterial effects of vasopressor drugs are very rare. This study investigates the in vitro antimicrobial activity of the clinically used forms of vasopressors. Materials and methods: In vitro antimicrobial activities of vasopressor drugs of different concentrations were investigated by using the micro dilution technique. Microorganisms used in the test were Escherichia coli ATCC 25922, Yersinia pseudotuberculosis ATCC 911, Pseudomonas aeruginosa ATCC 10145, Listeria monocytogenes ATCC 43251, Enterococcus faecalis ATCC 29212, Staphylococcus aureus ATCC 25923, Bacillus cereus 702 Roma, Mycobacterium smegmatis ATCC607, Candida albicans ATCC 60193, and Saccharomyces cerevisiae RSKK 251. Antibacterial assays were performed in Mueller-Hinton broth at pH 7.3 and antifungal assays were performed in buffered Yeast Nitrogen Base at pH 7.0. Results: Two different dopamine preparations showed antimicrobial activity. No other study drug showed any antimicrobial activity. Conclusions: In our opinion, dopamine's antibacterial effects may be advantageous for inhibiting the spread of bacterial contamination during the preparation of the infusion solutions. However, it is important that strict guidelines regarding the need for sterile equipment and deliverables be adhered to during all procedures performed in the intensive care units. .

Justificativa y objetivo: Los medicamentos administrados como perfusión intravenosa pueden ser contaminados durante las diversas etapas de producción o preparación. Sin embargo, son muy raros los estudios existentes sobre los efectos antibacterianos de los vasopresores. Este estudio investiga la actividad antimicrobiana in vitro de las formas de vasopresores usados clínicamente. Materiales y métodos: Actividades antimicrobianas in vitro de sustancias vasopresoras de diferentes concentraciones fueron investigadas con el uso de la técnica de microdilución. Los microrganismos usados en el test fueron: Escherichia coli ATCC 25922, Yersinia pseudotuberculosis ATCC 911, Pseudomonas aeruginosa ATCC 10145, Listeria monocytogenes ATCC 43251, Enterococcus faecalis ATCC 29212, Staphylococcus aureus ATCC 25923, Bacillus cereus 702 Roma, Mycobacterium smegmatis ATCC607, Candida albicans ATCC 60193 y Saccharomyces cerevisiae RSKK 251. Los ensayos antibacterianos se hicieron en un caldo de cultivo Mueller-Hinton (pH 7,3) y los ensayos antifúngicos en una solución tapón de base nitrogenada para levadura (pH 7,0). Resultados: Dos preparaciones diferentes de dopamina mostraron actividad antimicrobiana. Ninguna otra sustancia del estudio mostró alguna actividad antimicrobiana. Conclusiones: En nuestra opinión, los efectos antibacterianos de la dopamina pueden ser ventajosos para inhibir la propagación de la contaminación bacteriana durante la preparación de las soluciones para perfusión. Sin embargo, destacamos la importancia del seguimiento riguroso de las directrices de esterilización de los equipos y de asepsia durante todos los procedimientos realizados en las unidades de cuidados intensivos. .

Management of sepsis

Severe sepsis and septic shock are common and life-threatening medical conditions characterized by an overwhelming infection and the body's inflammatory response to that infection. Early and appropriate management of sepsis significantly reduces short-term and long-term mortality. Fluid resuscitation for shock and appropriate early antibiotic therapy have the most impact on survival. Source control should be accomplished within 24 hours where appropriate. Optimal management of sepsis requires early, goal-directed therapy; lung-protective ventilation; and antibiotics. The use of corticosteroids, vasopressin, and intensive insulin therapy requires further study. In this review, we have summarized the key components in the management of sepsis and septic shock, including early recognition, early resuscitation, principles of antibiotic therapy, organ support, and role of adjunctive therapies.

Effects of different vaso pressor on puerperant with caesarean section and newborn / 中国医师进修杂志

Objective To study the effects of ephedrine and phenylepbedrine for maintenance of arterial pressure during combined spinai/epidural anesthesia (CSEA) for caesarean section. Methods Forty patients, ASA grade Ⅰ - Ⅱ, who were scheduled for caesarean section by CSEA were randomly divided into two groups, when patients were hypotension, phenylephedrine 100 μg (group P, 20 cases ) or ephedrine 10 mg (group E, 20 cases). The variety of blood pressure (Bp), heart rate (HR) and oxyhemoglobin saturation (SpO2) were monitored; recorded before anesthesia (T0), at 15 min after anesthesia (T1), fetuses were taken out of uterus (T2) and at the end of operation (T3); umbilical arterial blood gas analysis was monitored; neonatal Apgar score was investigated. Results Umbilical arterial blood gas analysis of pH,PaO2, PaCO2, HCO3-, SaO2 were normal in two groups, there were no significant difference in PaO2, PaCO2 and SaO2 between two groups, but pH and HCO3- in group P were higher than those in group E [7.38±0.07 vs7.30±0.02 and (21.5±3.4) mmol/L vs (19.3±3.3) mmol/L] (P <0.05). There were no significant difference in Apgar score and Bp between two groups. Compared with group P, the HR in group E was increased obviously at T1 and T2 (P < 0.05). Conclusion Phenylephedrine is the vasopresser that most closely meets the criteria for the best vasopressor to use in obstetric patients.

Hormonal Changes of the Brain-Dead Organ Donors: A 3-Year Experience / 대한구급학회지

BACKGROUND: Success of transplantation is critically dependent upon the quality of the donor organ and optimal management. Recently, hormonal replacement therapy has been reported to result in rapid recovery of cardiac function and enable significantly more organs to be transplanted, while some other studies show conflicting results. The aim of this study is to comprehensively evaluate changes in basal circulating hormonal levels of the brain-dead organ donors. METHODS: We reviewed the records of all brain-dead patients between January, 2004, and June, 2007. Hemodynamic variables, plasma hormone levels were recorded at following time points: admission to the ICU (T1, baseline), 30 minutes (min) after first apnea test (T2), 30 min after second apnea test (T3), before operation for harvesting (T4). Hormonal measurements included cortisol, adrenocorticotrophic hormone, triiodothyronine (T(3)), thyroxine, free thyroxine, thyroid-stimulating hormone, growth hormone, and testosterone. RESULTS: Nineteen patients were included in this study. Comparisons of hemodynamic parameters and hormonal levels to baseline values revealed no significant changes throughout the study period. When the patients were divided into 2 groups according to the requirement of norepinephrine (either>0.05 or 0.05microgram/kg/min of norepinephrine had T(3) level below the normal range at significantly more time points of measurement (7 vs. 0). CONCLUSION: In this comprehensive assessment of hormonal levels in brain-dead organ donors, we could not observe any significant changes during the ICU stay. Replacement therapy of T(3) may be considered in patients requiring >0.05microgram/kg/min of norepinephrine.

Intensive management of acute right heart failure / 소아과

Not a few patients in children and adolescents are suffering from right ventricular (RV) dysfunction resulting from various conditions such as chronic lung disease, left ventricular dysfunction, pulmonary hypertension, or congenital heart defect. The RV is different from the left ventricle in terms of ventricular morphology, myocardial contractile pattern and special vulnerability to the pressure overload. Right ventricular failure (RVF) can be evaluated in terms of decreased RV contractility, RV volume overload, and/or RV pressure overload. The management for RVF starts from clear understanding of the pathophysiology of RVF. In addition to correction of the underlying disease, management of RVF per se is very important. Meticulous control of volume status, inotropic agents, vasopressors, and pulmonary selective vasodilators are the main tools in the management of RVF. The relative importance of each tool depends on the individual clinical status. Medical assist device and surgery can be considered selectively in case of refractory RVF to optimal medical treatment.

Intensive management of acute right heart failure / 소아과

Not a few patients in children and adolescents are suffering from right ventricular (RV) dysfunction resulting from various conditions such as chronic lung disease, left ventricular dysfunction, pulmonary hypertension, or congenital heart defect. The RV is different from the left ventricle in terms of ventricular morphology, myocardial contractile pattern and special vulnerability to the pressure overload. Right ventricular failure (RVF) can be evaluated in terms of decreased RV contractility, RV volume overload, and/or RV pressure overload. The management for RVF starts from clear understanding of the pathophysiology of RVF. In addition to correction of the underlying disease, management of RVF per se is very important. Meticulous control of volume status, inotropic agents, vasopressors, and pulmonary selective vasodilators are the main tools in the management of RVF. The relative importance of each tool depends on the individual clinical status. Medical assist device and surgery can be considered selectively in case of refractory RVF to optimal medical treatment.

Terlipressina como novo recurso terapêutico no choque séptico: [revisão] / Terlipressin as a new therapeutic agent in septic shock: [review]

JUSTIFICATIVA E OBJETIVOS: A terlipressina tem sido inserida em protocolos de suporte hemodinâmico da sepse, como recurso em casos de choque refratário, o que motiva análise crítica a respeito do assunto. CONTEÚDO: Foram revistas para a análise terapias hemodinâmicas com objetivos finais bem delineados e novas recomendações para reanimação volêmica, uso de vasopressores e agentes inotrópicos em adultos e crianças sépticos. CONCLUSÕES: A terlipressina tem sido considerada nova alternativa nos cuidados intensivos da sepse, embora ainda controversa.

BACKGROUND AND OBJECTIVES: The hemodynamic support of sepsis is now formulated trying to insert terlipressin as salvage drug in catecholamine resistant shock, justifying a broad critical analysis. CONTENTS: The analysis included hemodynamic therapies with defined specific goals and new recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult and pediatric patients. CONCLUSIONS: Terlipressin appears as a new but controversial alternative for vasopressor therapy in sepsis.

Effect of Rilmenidine and Clonidine Premedication on the Cardiovascular Action of Phenylephrine and Nitroprusside in Rats / 대한마취과학회지

BACKGROUND: Patients premedicated with clonidine often present with hypotension and bradycardia. The hypotensive patient premedicated with clonidine should be given a vasopressor to treat hypotension. In these patients, an augmented vasopressor response would be shown. Rilmenidine as an allied drug of clonidine is an antihypertensive agent with selectivity for the imidazoline receptor that acts centrally by reducing sympathetic overactivity. This study was designed to evaluate the effect of clonidine and rilmenidine on changes in mean blood pressure and baroreflex sensitivity following phenylephrine and nitroprusside administration. METHODS: Sixty Sprague-Dawley rats were assigned randomly into one of three groups, control group (n = 20), clonidine group (n = 20) or rilmenidine group (n = 20). Saline (control group), clonidine 30ng/kg (clonidine group) or rilmenidine 300ng/kg (rilmenidine group) were intraperitoneally injected respectively. Following the injection, a phenylephrine and nitroprusside test were performed. RESULTS: The percent change in mean blood perssure from the baseline values in the control group, clonidine group and rilmenidine group were 35 +/- 18%, 54 +/- 17% and 62 +/- 38%, respectively. There was no difference between the baroreflex sensitivity in the pressure (phenylephrine) test (0.94 +/- 0.43, vs 1.05 +/- 0.62, vs 1.13 +/- 0.59 msec/mmHg). In contrast, the slopes of the depressor (nitroprusside) test were decreased in rats receiving clonidine and rilmenidine (0.51 +/- 0.34, vs 0.12 +/- 0.08, vs 0.18 +/- 0.09 msec/mmHg, P < 0.05). CONCLUSIONS: It is concluded that the rilmenidine and clonidine groups showed a more augmented pressure response to vasopressors than the control group. Therefore, the decreased dosage of vasopressors is recommended to treat hypotension in rilmenidine premedicated patients.